INTRODUCTION

With today’s aging population, musculoskeletal diseases such as

osteoporosis, degenerative arthritis, and degenerative spine disease,

are on the rise, and these conditions are associated with increased

fracture risk. Intertrochanteric fractures in elderly patients often in-

volve severe displacement or comminution with poor bone quality.1)

Accordingly, various treatment methods for hip fracture have been

introduced.

The incidence of fixation failure is reported to be as high as 20%

in unstable intertrochanteric fracture due to nonunion, metal fail-

ure, and femoral perforation. Also postoperative ambulation may

be delayed in this population due to the difficulty of achieving

firm fixation.2) In addition, when fixation failure happens, reopera-

tion may not be possible due to the patient’s general condition and

medical complications.3,4) In comparison, bipolar hemiarthroplasty

is performed as an alternative to osteosynthesis in elderly patients

with unstable fracture patterns regardless of bone quality, and early

ambulation is possible if stable fixation is attained.5) In cases of poor

bone quality, cemented fixation was used in the past to enhance the

initial fixation strength.6) A cemented stem is advantageous for stable

fixation, early weight bearing, and less thigh pain, but it increases

the operation time and blood loss, and complications such as car-

diovascular toxicity.7-10) In the past, cementless fixation was not fa-

vored because it led to problems with initial fixation strength, bone

ingrowth, subsidence of the stem and intraoperative periprosthetic

fracture. However, with improvements in implant design, material,

pISSN : 1226-2102, eISSN : 2005-8918483

Copyright © 2015 by The Korean Orthopaedic Association

“This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.”

The Journal of the Korean Orthopaedic Association Volume 50 Number 6 2015

Received May 28, 2015 Revised July 23, 2015 Accepted August 19, 2015Correspondence to: So Hak Chung, M.D., Ph.D.Department of Orthopaedic Surgery, Kosin University Gospel Hospital, 262 Gamcheon-ro, Seo-gu, Busan 49267, KoreaTEL: +82-51-990-6467 FAX: +82-51-243-0181 E-mail: shchung@kosin.ac.kr

Original Article J Korean Orthop Assoc 2015; 50: 483-490 • http://dx.doi.org/10.4055/jkoa.2015.50.6.483 www.jkoa.org

Bipolar Hemiarthroplasty for Unstable Intertrochanteric Femur Fracture in Patients over the Age of 80 Years: Comparative

Analysis between Cementless and Cemented StemYoung Dae Jeon, M.D. and So Hak Chung, M.D., Ph.D.

Department of Orthopaedic Surgery, Kosin University Gospel Hospital, Busan, Korea

Purpose: The purpose of this study was to evaluate the effectiveness of bipolar hemiarthroplasty for unstable intertrochanteric fracture in patients over the age of 80 years.Materials and Methods: Sixty-two patients (62 cases) who had unstable comminuted intertrochanteric fractures between January 2007 and February 2012 were evaluated. All patients were over 80 years old at the time of the diagnosis, and were followed-up for at least 12 months. Patients were divided into two groups: those who received cementless stems (group 1, n=32) and those who received cemented stems (group 2, n=30). Functional results including Harris hip score, thigh pain, Koval’s ambulatory classification, postoperative mortality rate, operation time, and the amount of blood loss were evaluated. Results: The operation time and the amount of blood loss were significantly lower in group 1 compared to group 2. The Harris hip score was 82.1±8.6 points for group 1 and 83.4±7.5 points for group 2 at the final follow-up. One patient with poor cement press-fit level in group 2 experienced thigh pain. Twenty-seven patients (84.4%) in group 1 and 25 patients (83.3%) in group 2 recovered pre-injury ambulatory status. During the follow-up period, overall, 6 patients (18.8%) in group 1 and 8 patients (26.7%) in group 2 died. No significant differences in follow-up mortality rates were observed between the two groups. Conclusion: Considering the satisfactory clinical results, cementless bipolar hemiarthroplasty may be a good treatment option for patients over 80 years old with unstable intertrochanteric fracture.

Key words: unstable intertrochanteric fracture, bipolar hemiarthroplasty, cemented, cementless, elderly patients

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Young Dae Jeon and So Hak Chung

and insertion techniques, cementless fixation has gained popularity

because it facilitates initial strength and late biological fixation.11)

Lim et al.12) reported excellent ambulatory recovery of femoral

neck and intertrochanteric fractures after bipolar hemiarthroplasty

in patients over 80 years old. However, the study for bipolar hemi-

arthroplasty for unstable intertrochanteric fracture in patients over

80-year-old is rare. In this study, we aimed to evaluate the clini-

cal and radiological outcomes of cementless and cemented bipolar

hemiarthroplasty for unstable intertrochanteric fractures in patients

over 80-year-old.

MATERIALS AND METHODS

1. Subjects

Between January 2007 and February 2012, 62 patients over 80-year-

old, who underwent bipolar hemiarthroplasty for unstable inter-

trochanteric femur fracture at our institution were included in this

retrospective study. All patients had unstable fractures according to

the Evans classification. Patients with pathologic fractures, previous

contralateral hip fractures, stable fractures, osteoarthritis, or rheu-

matoid arthritis in the fractured hip, and nonfunctional ambulatory

before injury were excluded in the study.

Thirty-two patients received cementless stems (group 1), and 30

patients received cemented stems (group 2). There were 12 men and

20 women in group 1, 10 men and 20 women in group 2. The mean

age was 84.5±3.2 years in group 1 and 84.2±3.7 years in group 2.

The mean T-score of femur neck bone mineral density was -3.7±

0.3 in group 1 and -3.9±0.2 in group 2. Comorbidity scores were

recorded before surgery by using the American Society of Anes-

thesiologists criteria (Table 1). Minimum follow-up was 12 months

(mean, 24 months; range, 12-40 months).

2. Surgical methods and postoperative treatmentsSurgery was performed by the same surgeon in all cases. In both

groups, the transgluteal approach (Hardinge approach) was used

in the lateral position. The cementless stems used for group 1 were

Summits Basic Press-fit Stem (Depuy, West Chester, PA, USA) in

twenty cases and Bencox ID Stem (Corentec, Cheonan, Korea) in

twelve cases. The cemented stems used for group 2 were Summits

Basic Cemented Stem in twenty cases and Bencox ID Cemented

Stem in ten cases. For stable reduction and fixation with cement-

less stems, proximal fixation of the implant was reinforced with

additional wire fixation of the lesser trochanter and posteromedial

area. To prevent deep vein thrombosis, compressive stockings

were applied to both legs. Quadriceps femoris muscle strengthen-

ing exercises were begun one day after surgery. The postoperative

rehabilitation using tilting table, parallel bar walking, and walker

ambulation were performed depending on the patient’s conditions,

after removal of the drainage tube.

3. Clinical and radiological function assessments

For the clinical assessment, length of hospital stay, operation time,

blood loss during surgery, time until postoperative weight bearing

ambulation, last follow-up Harris hip scores (90-100: excellent, 80-

89: good, 70-79: fair, ＜70: poor) and thigh pain were assessed.

Ambulatory ability were assessed according to the Koval’s classifi-

cation (grade I: independent community ambulator, grade II: com-

munity ambulator with cane, grade III: community ambulator with

walker/crutches, grade IV: independent household ambulator, grade

V: household ambulator with cane, grade VI: household ambulator

with walker/crutches, grade VII: nonfuctional ambulator)13) show-

ing best ambulatory status within 12 months after surgery compared

to pre-fracture level considering elderly patients. Mortality rates of

the groups in follow-up period were recorded and reported as peri-

operatively, 1-year and 2-year mortality rates. For the radiological

assessment, anteroposterior and lateral radiographs of the hip were

taken at 6 weeks and at 3, 6, 9, and 12 months after surgery, as well

as every year thereafter.

Table 1. Patient’s Demographics and Clinical Results of Two Groups

Variable Group 1 (n=32) Group 2 (n=30) p-value

Sex 0.605

Male 12 10

Female 20 20

Age (yr) 84.5±3.2 84.2±3.7 0.366

BMD -3.7±0.3 -3.9±0.2 0.576

ASA classification

I, II 10 6 0.291

III, IV 22 24 0.455

Hospital stay (d) 16.5±3.2 17.1±4.2 0.451

Operation time (min) 85.0±4.1 97.0±5.3 0.012

Blood loss (ml) 395.0±40.2 445.0±37.5 0.004

Time to ambulation after surgery (d)

5.0±0.7 5.0±0.6 0.726

Harris hip score 82.1±8.6 83.4±7.5 0.485

Values are presented as number only or mean±standard deviation. BMD, bone mineral density; ASA, American Society of Anesthesiologists.

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Cementless Bipolar Hemiarthroplasty in Patients over 80-Year-Old

Cementless stem stability was assessed in terms of bony ingrowth,

stable fibrous fixation, and instability of the prosthesis according

to the criteria of Engh et al.14) Femoral stem fixation was classi-

fied into press-fit and non-press-fit fixation. The degree of vertical

subsidence of the femoral stem was measured by using the distance

between the greater trochanter and the superolateral margin of the

stem.

Radiolucent lines, bone resorption, endosteal new bone forma-

tion, and osteolysis were examined in the seven zones described by

Gruen et al.15) Radiolucent line denoted the radiolucent area around

the stem surrounded by radiodense lines, and it was considered to

be present if it occupied 50% or more of any zone. Loosening of the

femoral stem was defined as the appearance of a radiolucent line

that was progressive or at least 1mm-thick in all zones, or the pres-

ence of continuous migration of the femoral stem.

The press-fit level of the cemented stem to the bone cement was

evaluated according to Kelley’s cement scoring system by using the

radiological images obtained immediately after surgery.16)

4. Statistics

Data are expressed as mean values with standard deviation. Dif-

ferences in variables were compared across subgroups with a chi-

square test for categorical variables and an independent t test for

numeric variables as appropriate. For comparison change in walking

ability between cementless and cemented groups, Wilcoxon signed

rank sum test was employed. For comparison follow up mortality

rate, chi-square test and Fisher’s exact test were employed. All sta-

tistical analyses were carried out using IBM SPSS ver. 21.0 statistical

software (IBM Co., Armonk, NY, USA). p-values less than 0.05

were considered as statistically significant.

5. Ethics

This study was approved by local ethics committee. All patients

provided written informed consent before undergoing the screening

procedures.

RESULTS

1. Clinical resultsThe mean hospital stay was 16.5±3.2 days for group 1 and 17.1

±4.2 days for group 2. The mean operation time was 85.0±4.1

minutes for group 1 and 97.0±5.3 minutes for group 2. The mean

blood loss was 395.0±40.2 ml for group 1 and 445.0±37.5 ml for

group 2. Operation time and amount of blood loss were significantly

lower in the cementless group compared to the cemented group (p

＜0.05). The mean time to weight bearing ambulation after surgery

was five days for both groups. The mean Harris hip score at last

follow-up was 82.1±8.6 points for group 1 and 83.4±7.5 points

group 2. Better than fair results of Harris hip score were obtained in

29 patients (90.6%) for group 1 and 27 patients (90.0%) for group 2.

None of patients in both group died perioperatively (Table 1). One

patient with poor cement press-fit level in group 2 experienced

thigh pain. The mean postoperative mortality rate within 1 year was

15.6% for group 1 and 20.0% for group 2. During the follow-up

period, overall, 6 patients (18.8%) in group 1 and 8 patients (26.7%)

in group 2 died. Regarding the follow-up mortality rates, there were

no significant difference between the groups (Table 2). Twenty-

seven patients (84.4%) in group 1 and 25 patients (83.3%) in group

2 recovered their preoperative ambulatory ability. Five patients

(15.6%) in group 1 and 4 patients (13.3%) in group 2 showed a one-

level decrease from their preoperative ambulatory ability. In group 2,

1 patient (3.3%) showed a two-level decrease; this patient had bed

rest due to aggravation of underlying diseases. Overall, 52 of 62 pa-

tients (83.9%) regained their preoperative ambulatory ability within

12 months after surgery (Table 3, 4).

2. Radiological results

According to the radiological findings at last-follow-up, a press-

fit was achieved for all patients in group 1. No cases of subsidence

of femoral stem more than 5 mm were encountered (Fig. 1). There

were no radiolucent lines around the femoral stem in any cases in

group 1. Heterotopic ossification was observed in 1 patient (3.1%)

in group 1. The postoperative cement press-fit level according to

Kelly’s cement scoring system was good in 29 patients and poor in

only 1 patient (3.3%) (Table 5). Unfavorable result of poor cement

filing was observed thigh pain. However, walker aided ambulation

was possible after pain control with medication (Fig. 2).

3. ComplicationsEach group had one case of pneumonia, which were treated with

Table 2. Mortality Rates in Follow-Up

Variable Group 1 (n=32) Group 2 (n=30) p-value

Perioperatively 0/32 (0) 0/30 (0)

1 year 5/32 (15.6) 6/30 (20.0) 0.652*

2 year 1/27 (3.7) 2/24 (8.3) 0.595†

Overall 6/32 (18.8) 8/30 (26.7) 0.456*

Values are presented as the number/total number (%). *chi-square test. †Fisher’s exact test.

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Young Dae Jeon and So Hak Chung

admission to the intensive care unit and using antibiotics. No joint

dislocation occurred during follow-up period, nor did symptomatic

deep vein thrombosis, fat embolism, and pulmonary embolism.

There were no intraoperative femoral fractures or deaths. Superficial

infection occurred as a postoperative complication in 2 patients (6.3%)

in group 1; the infection was cured with wire removal, curettage,

and intravenous antibiotics administration.

DISCUSSION

The incidence of all hip fractures is approximately 80 per 100,000

persons and is expected to double over the next fifty years as the

population ages.17) Anatomic reduction of the unstable intertro-

chanteric fractures in elderly patients with firm internal fixation is

difficult to achieve and maintain; accordingly, malunion, reduction

failure, and reoperation are common complications.18) Considering

the importance of early postoperative ambulation and rehabilitation,

bipolar hemiarthroplasty is considered one of the most effective pri-

mary treatment methods for unstable intertrochanteric fracture.19-21)

In 1958, Charnley22) was the first to use cement to achieve fixation

Table 4. Change in Ambulatory Ability at the 24-Month Follow-Up Compared with the Prefracture Level

Ambulatory ability Group 1 (n=32) Group 2 (n=30)

None (n) 27 25

One level decrease (n) 5 4

Two level decrease (n) 1

Wilcoxon signed rank sum test, p=0.048.

A B C

Figure 1. An 82-year-old woman with right hip pain. (A) Preoperative radiograph showing an unstable intertrochanteric fracture. (B) Cementless bipolar hemi-arthroplasty was performed three days after the injury. Cerclage wire was used to fix the greater and lesser trochanters. (C) Postoperative 36-month follow-up radiograph showing no position change or subsidence of the stem; the patient had recovered her pre-injury ambulatory ability without complications.

Table 3. Koval’s Ambulatory Ability* Results at 24 Months after Surgery

Group 1: cementless (prefracture ambulation)

24 months after surgery

1) 2) 3) 4) 5) 6) 7)Total (n)

1) 12 1 13

2) 9 1 10

3) 2 1 3

4) 2 1 3

5) 1 1 2

6) 1 1

7) 0

Total 12 10 3 3 2 2 32

Group 2: cemented (prefracture ambulation)

Last follow-up ambulation

1) 2) 3) 4) 5) 6) 7)Total (n)

1) 11 1 12

2) 10 1 11

3) 2 2

4) 1 1 2

5) 2 2

6) 1 1

7) 0

Total 11 11 3 1 0 4 0 30

Two-level decrease 1

*Categories of ambulation according to Koval et al.13) 1): independent com munity ambulator, 2): community ambulator with cane, 3): community ambulator with walker or crutches, 4): independent household ambulator, 5): household ambulator with cane, 6): household ambulator with walker or crutches, 7): non-functional ambulator.

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Cementless Bipolar Hemiarthroplasty in Patients over 80-Year-Old

in hip arthroplasty. However, particle induced osteolysis or implant

loosening, known as cement disease were reported in the 1970s.

Parvizi et al.10) found that elderly patients with preexisting cardio-

vascular conditions who underwent cemented arthroplasty were at

increased risk for intraoperative death compared to patients who

underwent elective hip arthroplasty.

Cemented fixation is advantageous for achieving initial implant

stability and early rehabilitation in cases of unstable intertrochanteric

fractures with poor bone quality. Haentjens et al.20) reported on 91

patients over the age of 75 whose unstable intertrochanteric or sub-

trochanteric fractures were treated with cemented bipolar hemiar-

throplasty; they found good functional results in 78% of patients. In

our study, cement filling was good in 96.7% of patients and ambula-

tory ability was good in 83.3% of patients.

The cementless stem can be used to prevent cement-related

complications, but stem migration due to bone ingrowth failure,

bone resorption, thigh pain, and stress shielding have been report-

ed.14,23) Archibeck et al.24) reported good long-term results in 86% of

78 cases, with improvements in stem design, stem components, and

surgical techniques. In our study, stable fixation was observed in all

cases in the cementless group at the last-follow-up, and patients

showed excellent recovery of ambulatory ability (84.4%).

Taylor et al.25) reported better function and better mobility in the

cemented group than in cementless group. In contrast, ambulatory

ability recovery results of our study groups are similar (83.3% in ce-

mented group, 84.4% in cementless group). For stable reduction of

an unstable fragment, Jones26) suggested a method of screw fixation

of the lesser trochanter fragment. In our study, additional wire fixa-

tion was performed in the posteromedial area, including the lesser

trochanter area, for stable reduction and fixation.

It is important for elderly patients to recover their preoperative

ambulatory ability. Early ambulation can prevent complications

caused by long-term bed rest, such as pneumonia, bedsores, and

poor general conditions. In our study, early ambulation was allowed

when stable fixation was achieved after femoral stem insertion, as

fast as possible considering the general condition of each patient.

Overall, 52 patients (83.8%) regained their preoperative ambulatory

ability.

Campbell et al.27) found that postoperative thigh pain in the ce-

Table 5. Kelly’s Cement Scoring System of Group 2

GradeNo. of case

Grade A 26

Complete filling of the medullary cavity by cement

Grade B 4

Slight radiolucency due to no filling of bone-cement interface

Otherwise excellent cementing

Grade C 1

Bone-Cement radiolucency 50%–99%

And/or cement bubble

And/or incomplete cement mantle (<1 mm in any zone)

Grade D 0

Complete bone-cement radiolucency on any view

And/or cement does not extend beyond prosthesis tip

And/or gross defects in cement mantle

A B C

Figure 2. An 85-year-old woman with left hip pain. (A) Preoperative radiograph showing an unstable intertrochanteric fracture. (B) Cemented bipolar hemiarthro-plasty was performed four days after the injury. Bone-cement radiolucency was noted. (C) Postoperative 10-month follow-up radiography showing greater and lesser trochanter fragment displacement, but the patient was able to ambulate with a walker after pain control.

488

Young Dae Jeon and So Hak Chung

mentless stem occurred in up to 22% of patients over two years and

was caused by unstable femoral stems and biological fixation failure.

In our study, no cases of thigh pain or reoperation due to stem sub-

sidence or stem fixation failure in the cementless stem group were

observed. It is considered to be due to the advanced stem design

with primary mechanical stability and superior biological fixation.

Because the posteromedial fragment provides essential resistance

to axial loading and stem migration, stable reduction in the pos-

teromedial area with wire fixation is important to reduce thigh pain

for unstable intertrochanteric fracture. In our study, all patients had

stable reduction of posteromedial fragment. Hossain and Andrew28)

reported 1% risk of perioperative death after hip fracture surgery.

Mortality rate at 1 year after surgery was reported as 17.2% to

27%.5,29) Our current study also supported the results reported in the

literature (19% in cementless group and 27% in cemented group).

However our results show no significant differences between the

groups.

In our current comparative study, we found that cementless

hemiarthroplasty had shorter surgical operation time and lesser

blood loss compared to cemented hemiarthroplasty. Cementless

hemiarthroplasty was thought to be helpful in preventing serious

medical complications that are associated with elderly patients.

Both cemented and cementless hemiarthroplasty groups showed

good functional results. The significance of our study is that it

showed a comparable functional result between cemented and ce-

mentless groups. Mortality rates and complications did not increase

in cementless group compared to cemented group.

The retrospective design, small sample size (62 cases) and the

short follow-up period can be considered as limitations of our study.

However, mid-to long term follow-up study are difficult due to

their remaining life expectancy considering that patients are over

80-year-old.

Since many elderly patients are transferred to nursing homes after

they are discharged from the hospital due to underlying diseases or

lack of cooperation from family members, these patients may also

need to be educated about compliance with follow-up instructions.

It is necessary to analyze the mortality and complications in future

multicenter studies.

CONCLUSION

Cementless bipolar hemiarthroplasty can be recommended for the

treatment of unstable intertrochanteric fractures in patients over

80-year-old with early mobilization, satisfactory functional results,

low rates of implant loosening, shorter surgery time, and lesser

blood loss compared to cemented hemiarthroplasty.

CONFLICTS OF INTEREST

The authors have nothing to disclose.

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80세 이상 고령의 불안정성 대퇴 전자간부 골절에서 시행한 양극성 인공 고관절 반치환술: 무시멘트 주대와 시멘트 주대의 비교

전영대 • 정소학

고신대학교 복음병원 정형외과

목적: 80세 이상 불안정성 대퇴 전자간부 골절에서 인공관절 반치환술의 유용성을 알아보고자 하였다.

대상 및 방법: 2007년 1월부터 2012년 2월까지 불안정성 대퇴 전자간부 골절로 인공관절 반치환술을 시행받고, 진단 당시 연령이

80세 이상인 환자 중 12개월 이상 추시가 가능하였던 62명(62예)을 대상으로 하였다. 무시멘트 주대를 사용한 군(1군, 32예), 시멘트

주대를 사용한 군(2군, 30예)으로 설정하였으며, 최종 추시 Harris 고관절 점수와 대퇴부 통증, Koval 분류에 의한 보행상태를 분석하

였다.

결과: 1군이 2군보다 유의하게 수술시간이 짧고, 실혈량이 적었다. Harris 고관절 점수는 최종 추시상 1군, 2군이 각각 82.1±8.6점,

83.4±7.5점이었다. 시멘트 충전이 불량한 1예에서 대퇴부 통증이 있었다. 수상 전 보행상태로 회복은 1군, 2군이 각각 27예(84.4%),

25예(83.3%)였다. 추시 중 사망률은 1군, 2군이 각각 6예(18.8%), 8예(26.7%)으로 두 군 간의 유의한 차이는 없었다.

결론: 무시멘트 인공 고관절 반치환술은 시멘트 주대와 비교하여 만족할만한 임상적 결과를 보여, 80세 이상 환자의 불안정성 대퇴

전자간부 골절의 치료에 적용할 수 있을 것으로 생각된다.

색인단어: 불안정성 대퇴 전자간부 골절, 인공 고관절 반치환술, 시멘트형, 무시멘트형, 고령

접수일 2015년 5월 28일 수정일 2015년 7월 23일 게재확정일 2015년 8월 19일책임저자 정소학49267, 부산시 서구 감천로 262, 고신대학교 복음병원 정형외과 TEL 051-990-6467, FAX 051-243-0181, E-mail shchung@kosin.ac.kr

pISSN : 1226-2102, eISSN : 2005-8918490

Copyright © 2015 by The Korean Orthopaedic Association

“This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.”

대한정형외과학회지：제 50권 제 6호 2015

Original Article J Korean Orthop Assoc 2015; 50: 483-490 • http://dx.doi.org/10.4055/jkoa.2015.50.6.483 www.jkoa.org